Thursday, December 17, 2009

Last week, I bravely expressed vigorous support for medical rationing. No one has yet sent the ‘death panels’ after me and I still have a pulse. This week, emboldened by my continued survival, I tread again into dangerous terrain. I will offer support for another policy that is accused of being the cause of ongoing hemorrhage of the health care system. Who would risk public opprobrium by expressing support for a practice that is so corrupt and evil? The Whistleblower knows no fear.

Caution! Any minors reading this post are strongly admonished to close this window immediately so that your impressionable minds won’t be irrevocably contaminated. I shall write the nefarious term in the smallest print allowable, hoping it will escape the attention of web censors and the D.C. Health Care Thought Police.

Fee-For-Service-Medicine

The hardest part of treating an addiction is to admit the problem publically. I stand before you with humility and hope.

"My name is Whistleblower and I am a FFS physician"

Only 11 steps to go.

I practice FFS medicine, which is felt my many to be a gangrenous limb of our health care system that needs to be excised. FFS physicians are portrayed as profiteers who are fleecing the system. Even our president offered a rather damning comment this past July.

"Right now, doctors a lot of times are forced to make decisions based on the fee payment schedule that's out there. ... The doctor may look at the reimbursement system and say to himself, 'You know what? I make a lot more money if I take this kid's tonsils out,'"

This comment really stuck in the throats of thousands of ENT (ear, nose and throat) physicians who were being accused of pushing a No Tonsil Left Behind policy. Perhaps, the president was misinformed that ENT stands for Everyone Needs a Tonsillectomy.

The president, who bristles at the suggestion that he may harbor some socialist tendencies, joins a chorus of ‘reformers’ who want physicians to salaried. Indeed, he champions large medical institutions that pay physicians by a fixed wage, as if this model could be extended nationally. Only under a salaried construct, they argue, will we phyisicans be unshackled from financial conflicts of interest that taint our advice to our patients. The word profit joins medical rationing and FFS on the dark list of evil phrases that should never be broadcast during family viewing hours. (Not to worry parents, these time slots are already reserved for Viagra, Levitra and Cialis advertisements.)

When I recommend a colonoscopy, I do so because of medical need. I have confessed in an earlier post, that there are other factors that can influence my advice, but financial gain is not one of them. FFS gives an incentive for practitioners to provide excellent customer service. Which physician will be more likely to squeeze you in for an appointment, stay late for you or meet you in the emergency room when you are sick? Will it be a physician who is paid for this extra performance, or one who is on salary? Of course, this is a generalization. There are excellent physicians on salary and average practitioners who are compensated by FFS. However, in general, folks perform better when they have an incentive to do so.

I know that many readers are convinced that salaried physicians are the right medicine. Why stop with doctors? Why not simply remove profit from all professions and trades? Do they argue that only physician financial conflicts of interest should be eliminated? Here are some other folks who operate in FFS and profit models.

Attorneys

Accountants

Plumbers

Auto mechanics

Business Owners

Consultants

Salesmen

Retailers

Investors

Capitalists

If FFS medicine is corrupt, then why shouldn’t we strike out at profit wherever it exists? Wouldn’t we all be better off if the folks who advised us and sold us stuff had nothing to gain personally from the transaction? See how silly this is sounding, at least for those of us who are avowed capitalists?

Is FFS medicine the best we can do? Perhaps not, but I’m not willing to demonize it. FFS is not the only compensation system that is flawed. Remember HMOs where physicians had an incentive to limit care? Patients loathed this system, which had an irredeemable conflict of interest. Will a replacement for FFS medicine have conflicts that are more pernicious than the current ones? I do not welcome a ‘reformed’ compensation system that pays me just for showing up or rates me using a new quality measurement metric that measures everything but actual medical quality. We need to think this through to make sure a new method to compensate physicians will be fair to the public and to the medical profession.

There are diverse opinions on this issue in the blogosphere. Gooznews, a prominent health blogger, believes that FFS should be eliminated. Medrants and Musings of a Distractible Mind point out that the current system does not reward cognitive effort and time. Dr. Wes, angry about the president’s tonsil gaffe, requested an apology on behalf on the medical profession. I doubt that one was received.

What have I learned from all this? The president has given me an idea on how I might reach higher toward a new goal in my practice. I think I can kill 2 tonsils with one stone. During one of my profit seeking FFS colonoscopies, I will use an extra long scope and try to snatch a pair of tonsils at the same time.

Sunday, December 13, 2009

In 1972, George Carlin, the irreverent comedian who believed that boundaries are meant to be crossed, listed the 7 dirty words that could never be aired. These were considered to be a broadcaster’s ‘never event’. While society’s prohibition against offensive language and images have relaxed exponentially, there are still words and expressions that are radioactive.

I am quite certain that health care reformers have conducted focus groups to determine which verbiage offends and which phrase soothes the skeptical public. Words matter. I used to think that studying linguistics was merely an academic pursuit for grad students. Not so. These wordsmiths can now find honest work on Capital Hill. They can educate politicians on the nuances of language and expression so that our elected officials can speak out of a third side of their mouths.

We all remember from the prior presidential campaign how a wayward sentence can be exploited by adversaries who are poised to pounce. Recall this remark that Barack Obama made on the campaign trail in San Francisco in 2008.

So it’s not surprising then that they [midwestern communities]get bitter, they cling to guns or religion or antipathy to people who aren’t like them or anti-immigrant sentiment or anti-trade sentiment as a way to explain their frustrations.

If only there had been a linguist on the speechwriting staff. Obama and his handlers wish there had been a 7 second delay so that his misunderstood remark could have been bleeped, like a Carlin epithet. I don’t fault the president for his oratorical misstep. Considering the unrelenting campaign schedule, it’s expected and forgivable that candidates are not on their game 24/7.

Health care reform (HCR) advocates know that words and phrases may matter more than substance. Seasoned D.C. pols make only occasional rhetorical gaffes. Freshmen congressmen, however, rely on linguistically-correct HCR cue cards so that their words will be on message. Obviously, there are pro and con versions for each side of the aisle.

HCR Opponents Say…............... HCR Supporters Say

Tax and Spend.....................................Invest in the Future

Clearly, I am no politician because I support medical rationing, and I’m not afraid to use the smokin' hot term. Indeed, we ration resources in our own home. Our income is finite. Our family cannot run a deficit year after year, leaving our kids or their kids to pay the bill. We have our priorities and fund those activities that we feel are critical. Like most families, we run out of money before we run out of worthy pursuits. Since our kids and us can’t have it all, this means that we are rationers. I hope that no outraged reader will report us to child protective services for negligent parenting.

Sure, the stakes in health care are higher, but the principle remains. Resources are finite and medical care is infinite. Consider this shocking development recently reported in The New York Times. A new drug, Folotyn, was approved by the Food and Drug Administration (FDA) this past September against lymphoma, a blood cancer. The tab? A mere $30,000 per month. This makes other chemotherapeutics that cost only 10 grand per month seem like bargain medicines. What does Folotyn deliver for a monthly cost that exceeds many Americans’ yearly earnings? Not much. It shrinks tumors in a minority of patients, a common claim of benefit by cancer drug advocates. However, just shrinking a tumor doesn’t make a person feel better or live longer. Indeed, no mortality advantage of Folotyn users was demonstrated.

Can we afford to spend fortunes of money on treatments, even if approved by the FDA, that have no meaningful proven value to patients? Let me respond boldly to my own inquiry. We can’t and we shouldn’t.

Other medbloggers have voiced concerns about the struggle to achieve cost control.

Medrants, an academic physician, writes that...we cannot control costs if we indiscriminately order every possible test, every new expensive drug, and provide futile care.

Dr. Val points out that other countries are more aggressive about prioritizing health benefits than we are. She writes that in Canada, expensive chemotherapies are not commonly covered by the national health plan, and in Britain, age is a determinant for transplant eligibility.

Medinnovations, a thoughtful blog by Richard Reece, M.D. states the obvious that the supply of health care is a limited resource, and the demand in an aging population is unlimited.

If the nation isn’t ready to ration hard, let’s at least ration easy and push back against expensive medical care of questionable or no value. This is the low hanging fruit. Harder choices will follow, and we will have to face them. Rationing can’t remain on the ‘dirty word’ list any more. We need to scream it out because it needs to be heard. Like Carlin, we need to break through some boundaries.

Sunday, December 6, 2009

I’m surprised that they haven’t thrown me out of the profession yet. In the past year alone, I have been sued for medical malpractice, committed a ‘never event’ and confessed to performing an unnecessary medical test on a patient. It’s a wonder that my medical license hasn’t been revoked. Keep in mind that the above events are only those transgressions that I have admitted to. Imagine the misdeeds, misadventures and misconduct that I’ve kept secret. Are handcuffs in my future?

For example, I should I have come clean that a 2nd medical malpractice case was recently filed against me. I received the thick envelope from noble and altruistic Cleveland barristers about 6 weeks ago. Once again, I saw my name in the good company of many other physicians and our local hospital. I reviewed my medical records and felt comfortable with the care I had provided. In a medical malpractice case, quality of medical care is important, but the truth won’t set you free. It’s the documentation, stupid! I believe that I practice good medicine, but I know that I am an obsessive documenter. The former is important to my patients, and the latter is appreciated by my lawyer.

I had a single meeting with my attorney to review the legal preliminaries. It was clear that he had studied all of the relevant documents and was prepared. He was a senior partner at the firm and looked so much like a lawyer, that I thought he must be an actor. He donned a well tailored conservative suit and had elegant silver hair. He wore reading specs that conveyed a professorial demeanor. He was measured in his speech. Did he know any law? I hope so, but who can tell? As marketers and advertisers know, packaging is more important than the contents.

I had no clue where my standard of care may have strayed from the community standard. Only a person with a law degree can make such a determination. After all, what do we doctors know about medical quality? A physician cannot be expected to offer an authoritative opinion whether medical care is within acceptable standards as would be practiced by a reasonable and prudent physician if said physician were faced with similar clinical circumstances and knew, or should have known, that the patient, known as "Victim A", had a condition or set of conditions that within a reasonable degree of medical probability may have resulted in an adverse outcome had the physician not instituted prudent and proper medical care and treatment in accordance with established medical custom and practice. (Disclosure: Legalese concocted by the Whistleblower and may not conform to the community legal standard.)

Making a medical standard of care determination is certainly beyond the intellectual reach of a concrete thinking gastroenterologist who spends a good portion of his time in rectums. Lawyers, however, are paid handsomely to unravel such insoluble questions. So, at the close of our meeting, I asked him straight out why he thought I was being sued.

The wizened attorney thought for a minute before responding. He leaned towards me and with focused eye contact stated, “I have no idea”. That made two of us.

In Ohio, filing a medical malpractice case against a doctor requires that a physician sign an affidavit of merit, a sworn statement, attesting that the standard of care was breached. While these affidavits are generally signed in advance of filing suit, judges will give plaintiffs some latitude and permit the case to be filed if an affidavit will soon follow. I am in this window period, when the plaintiff’s attorney is trolling around the state trying to pay off one of my colleagues for a signature. I don’t think he’ll find one, even though this service can earn a physician up to $1,000 an autograph. Maybe some of these guys should be thrown out of the profession.

How does anyone credibly defend a system that targets innocent physicians routinely, vaporizes tens of billions of dollars on defensive medicine and misses the vast majority of patients who have been the victims of true negligence? If physicians performed according to these standards, we'd all be in handcuffs.

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About Me

I am a full time practicing physician and writer. I write about the joys and challenges of medical practice including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When I'm not writing, I'm performing colonoscopies.